Guardian Angel Home Healthcare Services

“Encoding and transmitting OASIS CFR(s): 484.45(a) Standard: An HHA must encode and electronically transmit each completed OASIS assessment to the CMS system, regarding each beneficiary with respect to which information is required to be transmitted (as determined by the Secretary), within 30 days of completing the assessment of the beneficiary. This Standard is not met as evidenced by: Based on record review and interview, the Agency failed to encode and electronically transmit each completed OASIS assessment to the CMS system within 30 days of completing the assessment of the patient for 19 of 216 assessments processed for the time-period reviewed of 01/01/2024 to 12/31/2024. This failure resulted in quality data used to continuously improve the effectiveness of home healthcare and improve patient care failing to be reported to CMS in the required time frame. Findings included: Review of document titled “HHA Error Summary by Agency” for the time period of 01/01/2024 to 12/31/2024, the report identified Error #-3330. The description for Error #-3300 read in part, “Record Submitted Late: The submission date was more than 30 days after M0090 (item M0090 specifies the date the actual assessment was completed) on this new record.” The documentation further identified the number of assessments with this error was 19 assessments and the percentage of assessments with this error was 8% of assessments completed by the agency (216 completed total). In an interview completed with the Administrator on 09/23/2025 at 3:23 PM, Surveyor informed the Administrator that the OASIS HHA Error Summary by Agency indicated that 19 assessments of 216 that were submitted for the time of 01/01/2024 through 12/31/2024 were late. Surveyor asked the Administrator who was the responsible party at the agency for ensuring that OASIS assessments were submitted timely. Administrator responded that the SN was responsible for the final review and then the Office Coordinator exports the assessments. In an interview with the Former SN on 09/24/2025 at 11:55 PM, Surveyor informed Former SN that the OASIS HHA Error Summary by Agency indicated that 19 assessments of 216 that were submitted for the time of 01/01/2024 through 12/31/2024 were late. Surveyor asked Former SN to describe the process used for submitting OASIS assessments and why some of the assessments were late. Former SN stated that she oversaw that nurses were completing their assessment documentation on time and that when they were ready she would notify Office Coordinator that they could be submitted. Former SN stated that sometimes they ended up being late if they had an error that caused them to be returned or if a billing issue was discovered that would require them to make a correction. Surveyor asked if any of those late assessments fell under the following exclusion criteria: patients under 18 years old; pre and post-partum maternity services; personal care, housekeeping, or chore services; or patients who received care under a separate entity operation. Former SN stated that they did not have any patients that would have met those exclusion criteria. Surveyor asked if late submissions impacted patient care. Former SN responded that it did not impact patient care because they were still able to generate a plan of care and continue providing care for patients, even if the assessment was submitted late. In an interview with Office Coordinator on 09/24/2025 at 12:41 PM, Surveyor informed Office Coordinator that the OASIS HHA Error Summary by Agency indicated that 19 assessments of 216 that were submitted for the time of 01/01/2024 through 12/31/2024 were late. Surveyor asked Office Coordinator to describe his part in submitting OASIS assessments. Office Coordinator stated that after the Former SN worked with nurses and the coding program to ensure that assessments were ready, she would let him know that he could submit them. Surveyor asked why some of the assessments were submitted late. Office Coordinator stated that if nurses completed their assessment documentation too close to submission deadline and there was also an error in coding then assessments would bounce back and the agency would not have had time to fix those errors and submit it timely. Review of the Agency’s policy titled “OASIS Collecting, Encoding, and Transmitting,” no date, revealed “the agency must encode and electronically transmit each completed OASIS assessment to the CMS system, for each beneficiary with respect to which information is required to be transmitted within 30 days of completing the assessment of the beneficiary.””

“A review of all current medications CFR(s): 484.55(c)(5) A review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions, including ineffective drug therapy, significant side effects, significant drug interactions, duplicate drug therapy, and noncompliance with drug therapy. This Element is not met as evidenced by: Based on observation, record review, and interview, the agency failed to maintain a current medication list for 2 of 3 patients for which home visits occurred (Patient 6 and Patient 7). This failure placed patients at risk of undetectable adverse events due to medications. Findings included: Record review of document titled “Medication Profile,” dated for the certification period of 08/08/2025 – 10/06/2025, revealed that the current list of medications for Patient 6 included the following: Buspirone HCl 15 mg, Semaglutide 0.25 mg/mL, Amlodipine Besylate 10 mg, Gabapentin 300 mg, metformin HCl 500 mg, Insulin Glargine 100 unit/mL, Lantus Solostar 100 unit/mL, Rifaximin 550 mg, Mirtazapine 30 mg (listed twice, once with instructions to take one tablet at bedtime and once with instructions to take one tablet daily), Lactulose 10 gm/15mL, Thiamine HCl 100 mg, Sucralfate 1 gm, Pantoprazole Sodium 40 mg, Nitrofurantoin Macrocrystal 100 mg, Nicotine Transdermal 7 mg/24 hr, Midodrine HCl 5 mg, Furosemide 20 mg, Folic Acid 1 mg, Multivitamin Men, Venlafaxine HCl ER 75 mg, and Ergocalciferol 1.25 mg. The medication list did not include Metformin 1000 mg or Mirtazapine 15 mg, despite those medications being observed amongst Patient 6’s medications. The medication list included Semgalutide 0.25 mg/mL. Metformin 500 mg, Mirtazapine 30 mg (listed twice), Lactulose 10 gm/15 mL, Thiamine HCl 100 mg, Sucralfate 1 gm, Pantoprazole Sodium 40 mg, Nitrofurantoin Macrocystal 100 mg, Nicotine transdermal 7 mg/ 24 hr, Midodrine HCl 5 mg, Furosemide 20 mg, Folic Acid 1 mg, Multivitamin Men, and Ergocalciferol 1.25 mg but they were not present amongst Patient 6’s medications. Record review of document titled “LPN/LVN – Skilled Nursing Visit,” dated 09/09/2025 revealed the following comments under the pain assessment section” Medications patient takes for pain: Tylenol as needed.” The note further included “SN provided patient with medication box and assisted patient to fill this medication box with his prescribed medications as a reminder for his weekly use.” LVN A also marked that there had not been any changes in medications since the last visit. There is no note included stating that Patient 6 was running out of medications or that LVN A called to refill medications. There are no coordination notes or other documented communications included in this visit about Patient 6 needing refills. Record review of document titled “LPN/LVN – Skilled Nursing Visit,” dated 09/16/2025 revealed the following comments under the pain assessment section” Medications patient takes for pain: Tylenol as needed.” The note further included “SN provided patient with medication box and assisted patient to fill this medication boxw with his prescribed medications as a reminder for his weekly use.” LVN A also marked that there had not been any changes in medications since the last visit. There is no note included stating that patient 6 was running out of medications or that LVN A called to refill medications. There are no coordination notes or other documented communications included in this visit about Patient 6 needing refills. Record review of document titled “OASIS - E1 Recertification,” dated 08/05/2025, revealed that RN A completed a recertification reassessment for Patient 6. RN A wrote in the assessment “at this time patient [family] do not help patient with his daily activities, meals or medication management.” RN A indicated “Tylenol as needed” as part of Patient 6’s pain management. Included in the orders, RN A indicated “SN to remove any duplicate or expired medications to prevent confusion with medication regimen.” RN A included in his narrative note “patient with no changes to medication.” During a home visit on 9/23/2025 at 10:33 AM, Surveyor requested to see Patient 6’s medications and compared them to the medication list obtained from the HHA’s electronic medical record the day prior. Surveyor observed a medication bottle with a label titled “Metformin 1000 mg,” with a refilled dated of 09/05/2025. Surveyor observed a pill bottle with the titled “Mirtazapine 15 mg,” with a refilled date of 10/08/2024. This bottle included instruction for the patient to take 1 half tablet at night. Surveyor asked Client 6 if he still took these medications since they differed from his medication list. Patient 6 stated that he was not entirely sure because LVN A filled his pillbox. Surveyor asked Patient 6 how long he had taken Metformin 1000 mg once daily and if he had ever taken Metformin 500 mg twice daily (as indicated on the HHA medication list). Patient 6 said he could not remember. LVN A stated that he was not aware that what the patient had in the home was different than on the HHA medication list. Surveyor asked LVN A for clarification of the Mirtazapine dose. LVN A stated that he believed those were 30 mg pills in an old pill bottle. Surveyor responded that Mirtazapine 30 mg is listed on the medication list twice, with one indicated as once daily and one indicated as once nightly, and asked if Patient 6 was taking it twice a day, for a total of 60 mg. LVN A responded that he was not taking it twice a day, that the 30 mg is broken in half and he takes 15 mg in the morning and 15 mg at night. Surveyor asked why 30 mg tablets would be in a pill bottle labeled for 15 mg tablets. LVN A and Patient 6 stated they did not know, sometimes patients combine a new prescription with leftovers of the previous. Surveyor asked Patient 6 if he was aware of what milligram of mirtazapine was currently in the pill bottle. Patient 6 stated he was not sure. Surveyor asked Patient 6 if he was taking or ever took Semaglutide. Patient 6 stated that he was on it but stopped about a month ago. Patient 6 stated he has had some issues with the getting medication refills. LVN A reported that Patient 6 does still take Rixamfin 550 mg, Thiamine HCl 100 mg, Sucralfate 1 GM, Pantoprazole Sodium 40 mg, Nitrofurantoin Macrocrystal 100 mg, , Midodrine HCL 5 mg, Furosemide 20 mg, Folic acid 1 mg, Multivitamin, Ergocalciferol 1.25 mg, and Lactulose 10 gm/15 mL, but Patient 6’s provider did not fill them because he had not been seen in too long. LVN A stated that they set up an appointment and Patient 6 was able to see his provider last week and that the prescriptions are being mailed. Surveyor asked Patient 6 and LVN A how long Patient 6 had been without the medications due to them not being refilled timely.? Neither Patient 6 or LVN A was able to provide an estimate. LVN A reported that Patient 6 does take Lactulose 10 gm/15 mL as needed. Surveyor reported that the medication list indicated it was being taken 4 times daily. Surveyor asked Patient 6 if he used transdermal nicotine patches. Patient 6 responded that he has never used those. In an interview with LVN A on 9/23/25 at 3:24 PM, Surveyor requested clarification on what medications that Patient 6 was taking. LVN A stated that Patient 6 stopped taking Semaglutide a month prior, that he never used nicotine patches, he takes 1000 mg of Metformin daily, and that he takes 30 mg of Mirtazapine at night. LVN A stated that he only ever asks the patient if there has been a change in medications and that he does not discontinue medications from the medication list even if the patient stated that they are no longer taking it unless he sees an order from the provider to discontinue a medication. LVN A stated that he used the HHA medication list to fill the patient’s pillbox. Surveyor asked how LVN A was able to fill the pillbox if the medication list is not reflecting the medications in Patient 6’s home and is incongruent with what LVN A stated the patient takes. LVN A stated that he did not have an explanation, that he just knows what Patient 6 was taking. Surveyor informed LVN A that after reviewing his visit notes with Patient 6, it was noted that LVN A documented within visit notes that Patient 6 used Tylenol for pain management. Surveyor asked why this was not reflected in the medication list. LVN A stated that he did not have an explanation for why it was not added to the list and why it was not congruent. Surveyor asked LVN A what attempts had been made to refill Patient 6’s medications. LVN A stated that he had called the ordering provider numerous times but never heard back. Surveyor asked if LVN A documented any of these communication attempts. LVN A stated no that he did not. Record review of document titled “Medication Profile,” dated for the certification period of 08/29/2025 – 10/27/2025, revealed that the current list of medications for Patient 7 included the following: Baclofen 10 mg, Buspirone HCl 10 mg, Methylprednisolone 100 mg/10 mL, Diphenhydramine HCl 50 mg/mL, Ocrevus 300 mg/10 mL, Zinc Oxide 15%, Polyethylene Glycol 3350, Reguloid 68%, Ketotifen Fumarate 0.025%, Escitalopram Oxalate 20 mg, Pantoprazole Sodium 40 mg, Tamsulosin HCl 0.4 mg, Advil Dual Action 125-250 mg, Aspirin EC Low Strength 81 mg, Spironolactone 100 mg, Acetazolamide 250 mg, Potassium Chloride ER 20 meq, and Gabapentin 300 mg. The medication list did not include Adapalene 0.3%, Albuterol 3/Ipratrop 0.5 mg/3 mL, Benzoyl Peroxide 5%, Buspirone HCl 15 mg, Cetirizine HCl 10 mg, Cholecalciferol 50 mcg (D3-2000 unit), Clotrimazole 1%, Escitalopram Oxalate 20 mg, Gabapentin 300 mg, Lidocaine 5%, Methylprednisolone 4 mg, Nystatin 10000 unit/gm, Potassium Chloride 10 meq, and Trazadone HCl 50 mg, despite those medications being observed amongst Patient 7’s medications and Patient 7’s caregiver providing confirmation that they were active medications. The medication list included Buspirone 10 mg, Methylprednisolone 100 mg/10 mL, Diphenhydramine HCl 50 mg/mL, Ocrevus 300 mg/10 mL, Zinc oxide 15%, Polyethylene Glycol 3350, Reguloid 68%, Ketotifen Fumarate 0.025%, Pantoprazole Sodium 40 mg, Tamsulosin HCL 0.4 mg, Advil Dual Action 125-250 mg, Aspirin EC Low Strength 81 mg, Spironolactone 100 mg, Acetazolamide 250 mg, and Potassium Chloride ER 20 meq but Patient 7’s caregiver confirmed they were not active medications and that they had been discontinued years ago. Review of document provided by Patient 7’s Caregiver, titled “Pre-Visit Summary,” dated 5/8/2025, reflected the medications that Patient 7’s Caregiver stated are all of Patient 7’s current medications, except for the Hydroxyzine 25 mg, which Patient 7 takes as needed at night. This document included the following medications: Adapalene 0.3%, Albuterol 3/Ipratrop 0.5 mg/3 mL, Baclofen 10 mg, Benzoyl Peroxide 5%, Buspirone HCl 15 mg, Cetirizine HCl 10 mg, Cholecalciferol 50 mcg (D3-2000 unit), Clotrimazole 1%, Escitalopram Oxalate 20 mg, Gabapentin 300 mg, Lidocaine 5%, Methylprednisolone 4 mg, Nystatin 10000 unit/gm, Potassium Chloride 10 meq, and Trazadone HCl 50 mg, This document did not include the following medications that were included on the HHA medication list: Buspirone 10 mg, Methylprednisolone 100 mg/10 mL, Diphenhydramine HCl 50 mg/mL, Ocrevus 300 mg/10 mL, Zinc oxide 15%, Polyethylene Glycol 3350, Reguloid 68%, Ketotifen Fumarate 0.025%, Pantoprazole Sodium 40 mg, Tamsulosin HCL 0.4 mg, Advil Dual Action 125-250 mg, Aspirin EC Low Strength 81 mg, Spironolactone 100 mg, Acetazolamide 250 mg, and Potassium Chloride ER 20 meq. Record review of document titled “OASIS - E1 Recertification,” dated 08/25/2025, revealed that RN A completed a recertification assessment for Patient 7 on 08/25/2025. This note indicated that Patient 7’s caregiver provided medication administration for Patient 7. RN A reported “patient with no changes to medication.” During a home visit on 09/24/2025 at 9:00 AM, Surveyor requested to see Patient 7’s medications and compared them to the medication list obtained from the HHA’s electronic medical record the day prior. Surveyor observed the following medications: Adapalene 0.3%, Albuterol 3/Ipratrop 0.5 mg/3 mL, Baclofen 10 mg, Benzoyl Peroxide 5%, Buspirone HCl 15 mg, Cetirizine HCl 10 mg, Cholecalciferol 50 mcg (D3-2000 unit), Clotrimazole 1%, Escitalopram Oxalate 20 mg, Gabapentin 300 mg, Lidocaine 5%, Methylprednisolone 4 mg, Nystatin 10000 unit/gm, Potassium Chloride 10 meq, Trazadone HCl 50 mg, and Hydroxyzine HCl 25 mg. Surveyor asked Patient 7’s caregiver about the other medications that were included on the HHA medication list. Patient 7’s caregiver retrieved a bag containing the following medications: Methylprednisolone, Spironolactone, Tamsulosin, Acetazolamide, Pantoprazole Sodium, and Aspirin. Patient 7’s Caregiver reported that Patient 7 has not taken these medications in about 2 years, they just have not discarded the medications. Surveyor asked Caregiver of Patient 7 when the dose for Buspirone had changed from 10 mg to 15 mg. Caregiver for Patient 7 stated that she could not remember, but it had been a while ago. Caregiver for Patient 7 was unable to answer additional questions as she had to return to work. In an interview with LVN B on 9/24/2025 at 9:50 AM, Surveyor asked LVN B about his process for medication reconciliation. LVN B stated that he had gone over medications with the Caregiver of Patient 7 and physically review the bottles, but that visit was the first time that he had heard that many of those medications were discontinued. Surveyor asked why new medications had not been recorded in the medication list if LVN B had physically reviewed the bottles. LVN B stated that he did not have an explanation. Surveyor asked LVN B how he was going to correct the medication list today since he did not go through the medication bottles himself with the caregiver at that visit. LVN B stated he would call the caregiver later to clarify the medications. In an interview with temporary SN and SN on 09/25/2025 at 10:52 AM, temporary SN stated that he served as supervising nurse from 7/11/2025 through 9/2/2025, until SN took over. Surveyor informed temporary SN and SN about the numerous discrepancies in medication lists versus what patients were actually taking for Patient 6 and Patient 7. Neither temporary SN nor SN had an explanation for why the medication lists were not accurate. Neither temporary SN or SN had received any messages from Patient 6 or LVN A to report that there was difficulty refilling medications. Surveyor reported that there was no way to determine what medications Patient 6 was actually supposed to be taking based off of the HHA medication list and what was present in the home. Surveyor reported that neither Patient 6 or LVN A were able to state how long Patient 6 had been without many of the medications that were on his medication list due to “awaiting refills.” Surveyor reported that LVN A stated he filled Patient 6’s pillbox, but was unable to provide an explanation for how he fills the medication box with the HHA medication list being inaccurate. SN stated she would contact LVN A to determine how the medication box was being filled and that she would contact the ordering provider for Client 6 to determine an accurate medication list. In an interview with RN A on 09/25/2025 at 12:08 PM, Surveyor asked about the medication reconciliation that took place with Patient 6 and Patient 7 during their most recent recertification assessment and why the medications that both patients were taking were not accurately reflected in their most recent plan of care. RN A stated that he did not know why they were not accurate and suggested that it could have been a technological error that prevented changes from being saved. Surveyor asked why the narrative of the assessment for Patient 6 noted “patient with no changes in medications,” but Mirtazapine 30 mg was listed as a duplicate on the previous certification and current certification period. RN A stated that he must have just missed that error. Surveyor stated that the actual medication in the bottle in Client 6’s home read Mirtazapine 15 mg, with instructions to break the pill in half. RN A stated that he must have just overlooked it. Surveyor informed RN A that his recertification note for Patient 6 indicated that Patient 6 used Tylenol for pain, but this was not added to his medication list. Surveyor reported that in this same note, RN A stated that there were no medication changes for the patient. RN A was unable to explain why Tylenol would have been mentioned in the note but not added to the list, and why the other medications were not accurate. Surveyor informed RN A that he had also indicated in his recertification note for Patient 7 that he had no changes in medication. RN A was not sure why their medications were not accurately reflected in the record. Surveyor summarized that RN A believed the medication lists were not accurate due to a combination of overlooking medication bottles and a potential technological error and RN A confirmed. RN A stated that all nurses involved in a patient’s care should be looking at the patient’s medications to ensure accuracy. In an interview with SN on 09/24/2025 at 1:00 PM, SN stated that she received an updated medication list from the ordering provider for Patient 6. SN stated that she had been unable to reach LVN A for an interview. In an interview with the Administrator on 09/24/2025 at 1:16 PM, the Administrator confirmed that ensuring that medications lists are accurate was the responsibilities of the nurses involved in patient’s care. Prior to the exit conference on 09/24/2025 at 2:00 PM, Surveyor asked SN if she had been able to contact LVN A for clarification on Patient 6’s medication management. SN stated that she still had not been able to reach him. Review of policy titled “Medication List and Monitoring,” no date, revealed that the “agency will maintain a current accurate list of all prescription and over-the-counter (OTC) medications taken by the patient.” The policy also stated the patient’s provider would be notified to reconcile medications in the event of any problems or discrepancies, and that notification would be documented in the clinical record.”